The newest heart failure management guidelines make a bold statement: Heart failure should no longer be considered a death sentence, but can instead be managed in a way that may add years of quality life for some patients.
“With optimal therapy applied to the right patient in the right manner at the right time, the risk of death can be markedly reduced, perhaps by as much as 50%. Treating fewer than 10 patients with all the correct therapies will easily save at least one life and one or more hospitalizations. Those are real benefits that dwarf the benefit of many of our other cardiovascular therapies,” said Dr. Clyde W. Yancy, chair of the joint guidelines writing committee. The document was published in the June 5 online edition of the Journal of the American College of Cardiology (2013 [doi:10.1016/j.jacc.2013.05.019]).
Dr. Clyde W. Yancy
"For so long, we had assumed that, by definition, heart failure was a fatal diagnosis – that all we could do was tell patients to get their affairs in order and perhaps make them feel a little better, but that death was almost a fait accompli," said Dr. Yancy, the Magerstadt Professor of Medicine and chief of cardiology at Northwestern University, Chicago. "But, in the past few years, a lot of tough work has been done showing there are effective therapies and that when given correctly, major improvements in survival do occur."
A joint effort of the American College of Cardiology Foundation and the American Heart Association, the 2013 Heart Failure Guidelines represent the first update on the topic since 2009, Dr. Yancy said in an interview. Although the years between the documents are few, the strides in research have been many, he said.
"The emergence of new and important datasets generated the impetus for the 2013 guideline not as an update, but as a complete rewrite. All of the previously extant clinical practice guideline statements were subject to reanalysis, a change in level of evidence and most importantly, a change in the class of recommendation," he said.
The document is among the first in the United States to employ the concept of guideline-directed medical therapy (GDMT) – a new designation that allows clinicians to easily determine the best course of heart failure care for an individual patient. Schematic algorithms provide easy-to-follow treatment pathways that should be helpful for anyone who treats heart failure patients, from specialist to primary care provider, said Dr. Yancy.
A major focus of the guideline is treating heart failure with preserved ejection fraction (HFpEF), with the goal of preventing or delaying progression. HFpEF is "a real entity" that constitutes about half of heart failure diagnoses, Dr. Yancy said, but as yet, has no specific intervention.
Until research provides further answers, the best way to manage HFpEF is holistically. "About 90% of these patients have comorbid conditions like hypertension, coronary artery disease, diabetes, renal insufficiency and atrial fibrillation. In the absence of a specific intervention for HFpEF, focusing on these other conditions will provide us the opportunity to modify the natural history of this disease."
Dr. David E. Lanfear, a cardiologist specializing in advanced heart failure and transplantation at Henry Ford Hospital in Detroit, said the guidelines on HFpEF “are very reasonable. The recommendations appear similar to those in previous statements, on blood pressure control, volume control for symptoms, atrial fibrillation, and ischemia, without endorsing specific medications. The statement also eloquently points out the ways in which HFpEF represents a huge gap in the knowledge base.
The guidelines contain "critical" new indications for the use of aldosterone antagonists, Dr. Yancy said. The drugs saw a surge in use in the early 2000s, but the rush to embrace them brought challenges as well. "Some of the applications led to missteps resulting in elevated potassium levels and emergency admissions," Dr. Yancy said. Since then, additional trials have pinpointed the best ways to use aldosterone agonists in patients who have heart failure with reduced ejection fraction or cardiac injury after heart attack. Data now confirm their benefit in patients with mild and moderate disease, as well as those with more advanced disease.
"This is the first document in the United States to embrace the benefit of aldosterone antagonists for these patients," Dr. Yancy said. Provided that patient renal function is "reasonably intact," the drugs are a valuable addition to GDMT.
The guidelines also offer a refinement of the recommendations for cardiac resynchronization device therapy – another change supported by the results of recent, large-scale trials. "We now have three separate, well-done trials that suggest a significant benefit of cardiac resynchronization in patients with mild to moderate disease," Dr. Yancy said.